March-April 2018 | No. 2, Vol. 8PUBLISHED IN DUBAI www.dental-tribune.me

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researchTitanium and its alloys in dental implantology

case reportRehabilitation of edentulous patients

industryDigital workfl ow: From planning to restoration

implants international magazine of oral implantology

issn 1868-3207 Vol. 18 • Issue 4/2017

4 2017

SUBSCRIBE NOWwww.me.dental-tribune.com/e-paper/Implant Restorations

with CEREC

By Dr Simon Chard, United Kingdom

Dental implants are a fantastic addi-tion to the repertoire of any restora-tive dentist and allow us to provide a tooth replacement in a way that minimises damage to remaining dentition. The restoration of dental implants requires a sound knowl-edge of restorative dentistry, pros-thodontics and periodontology.

Traditionally, this has been carried out with an analogue impression taken with an impression coping either via an open or closed tray im-pression technique. A skilled techni-cian then fabricates this restoration over a 2- to 3-week period. The time

and skill required for these restora-tions both from the clinician and technician command high fees for the patient.

This case report highlights a novel method of restoring implants utilis-ing the modern advances in digital intraoral scanning and chairside milling. It illustrates how an aesthet-ic single implant retained crown can be provided chairside without the need for analogue impressions (Figs. 1 & 2: Pre-operative condition).

Following a discussion of the options for replacement of LR6, the patient elected for an implant retained so-lution. A MegaGen AnyRidge 4 x 10

mm implant was placed utilising a surgical guide for position of the pilot hole. An immediate tempo-rary crown was fabricated using the MegaGen fuse abutment and DMG Luxatemp. A silicone index of the di-agnostic wax-up was fabricated and the temporary crown was polished and taken out of occlusion while the implant fully integrated (Fig. 3).

Following 3 months of integration, the patient attended the practice for the restoration of the implant with a definitive crown. During this period, the soft tissue had been given time to mature and a beautiful molar soft tissue profile had formed (Figs. 4 & 5).

Traditionally, capturing the detail of this soft tissue profile with analogue methods is complicated and time consuming; however, utilising a digi-tal intraoral scan (CEREC Omnicam) a “gingival mask scan” can be taken to accurately replicate this soft tissue and use it to guide the subgingival emergence profile of the restoration (Fig. 6).

Following removal of the temporary crown, a TiBase was placed into the fixture head and a scan body used as a reference point for the scanning of the implant (Figs. 7 & 8).

Following digital intraoral scanning (DIOS) of the opposing arch, working

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arch and buccal bite, a digital design was created using the biogeneric in-dividual design mode. In this design mode on the CEREC Omnicam, the software evaluates the other teeth captured in the DIOS and tries to recreate what it believes to be the

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Dental Tribune Middle East & Africa Edition | 2/2018 IMPLANT TRIBUNED2

closest match to the original missing tooth (Figs. 9–11).

This tooth design is then positioned digitally within an e.max meso block. This meso block has a predetermined hole within it that acts as the access hole for the screw-retained crown, as well as the orifice into which a TiBase will be bonded (Fig. 12).

This restoration is then milled from

the low translucency monolithic e.max CAD Block in its purple phase (taking around 18 minutes) and checked for precision of fit on the TiBase (Figs. 13 & 14).

It is tried in intraorally to assess contacts and occlusion in static and dynamic function (Figs. 15 & 16). The restoration is then stained us-ing Ivoclar e.max Crystall Glaze so as to provide an aesthetically har-

monious restoration and glazed with Glaze Spray. It is placed in an Ivoclar Vi-vadent Programat CS2 fir-ing furnace for 15 minutes to crystalise the ceramic, turning it from purple to tooth-coloured (Fig. 17).The ceramic restoration is then bonded onto the

TiBase extraorally. The fit surface of the ceramic is treated with 5 % Hy-drofluoric acid and silanated with Monobond Plus (Ivoclar Vivadent). The TiBase is sandblasted and also silanated. Finally, the ceramic and TiBase are bonded with multilink hy-brid resin cement (Ivoclar Vivadent; Figs. 18–21).

Following the bonding, the restora-tion is steam cleaned to remove any residue. The final restoration (Fig. 22) is now ready to be inserted, approxi-mately 2 hours after the patient ar-rived in the practice (Fig. 23).

The restoration is finally torqued down to 25 Ncm. Following this, occlusion is rechecked, but no ad-justment is required at this stage following the try-in adjustments.

PTFE is placed in the access cavity and the access hole filled with opa-cious composite (OMC Venus Pearl) and stained with Venus tints (Figs. 24–26).

In conclusion, as you can see in the final result (Figs. 27–29) an aesthetic, biologically designed and durable restoration has been fabricated. The patient has been delivered the final restoration in a single visit without the need for traditional analogue im-pressions.

Editorial note: A list of references is available from the publisher.

The article was originally published in CAD/CAM International Magazine 2/2017.

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Dr Simon Chard BDS(Hons) BSc(Hons) qualified with Hon-ours from King’s Col-lege London Dental Institute in 2012. He is director of member-

ship for the British Academy of Cosmetic Dentistry, was voted the Best Young Den-tist in the Dentistry Awards 2015 and is a member of the Association of Dental Implantology. Dr Chard is very passionate about providing beautiful, healthy smiles for his patients and is a big promoter of using digital technology to simplify cos-metic and implant dentistry.

Dental education is something that is a major part of his professional career and he has dedicated thousands of hours to advanced training from the best dentists around the world.

From titanium to zirconia implantsBy Sofia Karapataki, Greece

Zirconium is a metal with the atom-ic number 40. Zirconium dioxide (ZrO2) or Zirconia is a ceramic ma-terial without any metal properties. It is electrochemically inert causing no galvanising or electro current disturbance effects at an inter- and intracellular level. It is the most bioinert and biocompatible mate-rial currently available in the market, with no detected allergies or intoler-ances. The material exhibits lower surface free energy that leads to hy-drophilic reduced plaque (biofilm) accumulation, so, less inflammation is expected leading to superior soft tissue health.

Zirconia fulfils highly desirable aes-thetic results: healthy, pink and beau-tiful tissue can be created around an implant, with no tissue translucency. Its high aesthetics resembles natural tooth. Unlike titanium, it may stimu-late bone growth in the long-term with ultimate osseointegration for both bone and gum. In addition to the white colour, a low modulus of elasticity and thermal conductivity

have made zirconia implants a very attractive alternative to titanium in implant dentistry.1–4 With its inter-esting microstructural properties, zirconia is the material of choice for the “new generation” of implants. Hashim et al. (2016) made a system-atic review and evaluated the clinical success and survival rates of zirconia ceramic implants after at least one year of functioning.5 They concluded that in spite of the unavailability of sufficient long-term evidence to justify using zirconia oral implants, zirconia ceramics could potentially be the alternative to titanium for a non-metallic implant solution. This is also shown in the review made by Cionca et al. (2017), that through in vitro and in vivo studies, zirconia has managed to earn its place as a valu-able alternative to titanium.6

Mechanical and physical properties Zirconia though, is a totally different material than titanium. The thor-ough knowledge of implantology using titanium is not so easy to be transferred to zirconia, simply due

to different physical and mechanical properties of the materials. Knowl-edge of the potentials of the mate-rial is the key of success and the only chance to minimise failures. Zirconia (ZrO2) is a highly biocompatible ma-terial, but it needs to osseointegrate and withstand masticatory force without fracturing. A good product needs to be fabricated that would ful-fil all the necessary requirements in order to be successfully implanted.

ZrO2 is stable at room temperature at a monoclinic phase. Doped by yttrium oxide, when it cools down from 1,173 °C, a tetragonal phase sta-ble at room temperature (metasta-ble) is produced. This is the material used for implants. It is of major im-portance for the implant to be kept in the tetragonal phase to keep its mechanical and physical properties over time. It is well established that the stability of this phase is affected by several compositional parame-ters, including grain-size, processing conditions and quality control.

Purity or rather contamination with impurities, density and porosity

of the final product as well as pre-sintering and sintering process and time are also some of these param-eters. Environment or conditions (loading-temperature-humidity) in which the product will be used (it makes a difference whether zirconia is produced for a hip prosthesis or for dental implants) are to be kept in mind. And last but not least, han-dling of the material is of outmost importance.7,8 Lughi et al. (2010) sug-gested engineering guidelines for the use of zirconia as dental material.9

Producing zirconia implantsThere are two ways of producing zir-conia implants: through moulding and through milling of prefabricated rods. The first method produces im-plants with specific shape and spe-cific low roughness on their surface. Milling of the rods on the other hand, is done either on partially or fully sintered zirconia. The fabrication of an implant through soft machining of partially sintered ZrO2 provides the advantage of easier milling than the fully sintered ZrO2. It requires less milling time and causes less wear of the cutting tools.10, 11

In hard machining of fully sintered ZrO2, no sintering shrinkage is ex-pected and there is no need for a sin-tering oven. However, microcracks maybe introduced.10 Since diamond zirconia is known as the toughest material existing, only diamond tools are used for cutting sintered zirconia. The grinding of the fully sintered ZrO2 causes a certain degree of transformation (from tetragonal to monoclinic phase) in the surface of this material.12 When comparing

the final surface of the soft machined ZrO2 to the hard machined ZrO2, it is expected that the former will have a more consistent final state, given that it is left intact (no sandblasting or grinding) after the final sintering.13

The implants that are produced need to be roughened in order to be osse-ointegrated. Question arises what is the optimal roughness and surface that is produced after it, in order for zirconia implants to be successfully osseointegrated in any of the afore-mentioned production methods. It seems that the rougher the body, the better the odds for osseointegra-tion.14 This though should not be the goal for the head of the implant in case that it is visible in the mouth—it could favour bacteria colonisation. The best method to achieve the op-timal roughness as well as the mo-ment that this should be realised with respect to the material’s prop-erties is also not established. Finally, depending on the procedure, the roughened surface needs to be to-tally clean, free of all foreign bodies.

Ageing of titanium vs zirconiaAgeing of titanium implants is a not widely known phenomenon and starts four weeks after their produc-tion which decreases dramatically the osseointegration potential.15–18 Ageing of zirconia (Low Temperature Degradation LTD, i.e. the slow trans-formation of the metastable tetrago-nal crystals to the stable monoclinic structure in the presence of water or water vapour) on the other hand is quite well investigated.

ZrO2 is a highly biocompatible material that needs to

osseointegrate and withstand masticatory force without fracturing.

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Dental Tribune Middle East & Africa Edition | 2/2018IMPLANT TRIBUNE D3

THE ELEVENTH ANNUAL AMERICAN ACADEMY OF IMPLANT DENTISTRYMaxiCourse®- UAE 2018 – 2019 Starts 28 March 2018

A unique opportunity towards becoming anAmerican Board Certified Oral Implantologist*

In Fulfillment of the Educational Requirement for the Examination for Associate Fellow Membership and Fellowship for the

American Academy of Implant Dentistry

Program Includes placement of upto 10 Implants with all surgical and prosthetic components, all materials for hands – on workshops and lecture handouts plus one complete surgical instrument Kit.

MaxiCourse ® Advantage: 300 hours of comprehensive lectures, live surgeries,

demonstration and hands-on sessions. In depth review of surgical and prosthetic protocols. Sessions stretch across 5 modules of 6 days. Each

session is always inclusive of a weekend. Curriculun taught by over 18 faculty & speakers from

the International Community who are amongst the most distinguished names in implantology..

Certificate of completion awarded by the American Academy of Implant Dentistry.

Non commercial, non sponsored course covering a wide spectrum of implant types and system.

Hands-on patient treatment under direct AAID faculty supervision.

Membership for AAID awarded for 2017 – 2018

Dates: Mod u le 1 Mar ch 28 th – A pr i l 2nd 2018 Mod u le 2 J u ly 5th - 10 th 2018 Mod u le 3 A u g u st 23r d – 28 th 2018 Mod u le 4 N ovember 1st – 6 th 2018 Mod u le 5 J anu ar y 24th - 29th 2019

*AAID is the sponsoring organization ofABOI

Registration :

Pre-Registration is Mandatory as it is a limited Participation Program. For further information and registration details visit website: www.maxicourseasia.com or e-mail Dr. Ninette Banday, Co- Director AAID-MaxiCourse UAE at drnbanday@yahoo.com Dr. Mohammed Eid Allahham, Coordinator UAE at: m_eid_1992@hotmail.com or +971-56-7174417

The Faculty are as follows:

Dr. Shankar Iyer, USA Director, AAID Maxi Course®UAEDiplomate AAIDClinical Assistant Professor,Rutgers School of Dental Medicine.

Dr. Ninette Banday, UAECo-Director AAID Maxicourse- Abu Dhabi, UAEAcademic Associate Fellow AAID

Dr. Amit Vora, USADiplomate of the American Board of PeriodontologyProfessor (partime) ,JFK Hospital and the Veteran Affairs (V.A.) Hospital

Dr. Jaime Lozada, USADirector of the Graduate Program in Implant Dentistry Fellow, American Academy of Implant Dentistry

Dr. William Locante, USADiplomate of ABOIFellow of American Academy of Implant Dentistry

Dr. Robert Horowitz, USADiplomate American Board of Periodontology

Clinical Assistant Professor New York University

Dr. Frank LaMar, Sn USAFellow, American Academy of Implant DentistryDiplomate, American Board of Oral Implantology

Dr. Frank LaMar Jr.Diplomat American Board of Prosthodontist

Dr. John Minichetti, USADiplomat, American Board of Oral ImplantologyHonored Fellow, American Academy of Implant Dentistry

Dr. Kim Gowey, USAPast President – AAID Diplomate ABOI

Dr.Burnee Dunson, USAFellow, American Academy of Implant Dentistry Diplomate ABOI

Dr. Jason Kim, USADiplomate of ABOI

Dr. Ozair Banday, USAProsthodontist

Dr. Stuart Orton-Jones, UKFounder Member, The Pankey AssociationMember, Alabama Implant Study Group

Dr. Robert Miller, USABoard Certified by the American Board of Oral Implantology/Implant DentistryHonored Fellow American Academy of Implant Dentistry

Dr. Philip Tardeu, FranceFounder and Author, Computer Guided Implantology and the Safe System.

Dr. Natalie Wong, CanadaDiplomate, American Board of Oral ImplantologyFellow, American Academy of Implant Dentistry

Dr. Irfan Kanchwala, IndiaImplant Fellowship ( UMDNJ, USA)Diplomate , American Board of Prosthodontics

Dr. Jihad Abdallah, LebanonDiplomate American Board of Oral ImplantologyFellow AAIDProfessor & Head of Implantology Division, Faculty of Dentistry.Beirut Arab University

Dr.Bart Silvermann, USADiplomate, American Board of Oral ImplantologyOral & Maxillofacial Surgeon

2016-2017 Program Accredited by Health Authority Abu Dhabi for 228.5 CME Hours. Accredition of 2018 -2019 Program under Process

Degradation rates at room or body temperature of Y-TZP ceramics are currently not available, and acceler-ated tests at intermediate tempera-ture (100 to 300 °C) are the only basis for extrapolating an estimate of the transformation rate and, hence, of the product lifetime. This approach relies on the assumption that the transformation rate follows the same Arrhenius-like trend down to room/body temperature. Unfortu-nately, such extrapolation could lead to a signifi cant error in estimating room/body temperature lifetimes.9 Still this is the method that is used in researches. Monzavi M. et al. (2017) examined 36 zirconia implants of four different brands and found that the effect of ageing was minimal in all systems.19 They suggested though that in vivo studies are needed to investigate the effect of mastication force on the extent of LTD and the infl uence of surface changes such as delamination of the grains on sur-rounding hard- and soft-tissue.

Still a certain degree of transforma-tion from tetragonal to monoclinic phase can actually improve the me-chanical properties of Y-TZP. Under stress, i.e. at the tip of a crack, the Y-TZP undergoes a phase transforma-tion from tetragonal to monoclinic phase. This phase transformation results in a 3 to 4 per cent volumetric expansion inducing a compressive stress in the area of the crack and theoretically prevents crack propa-gation.1 An implant which exhibits phase transformation in case of microcracks and high forces is desir-able. Still it is not sure whether the already existing microcracks that are produced (for instance, during handling) during mastication or par-afunctional activities, don’t propa-gate, leading to a possible fracture.

One- vs two-piece zirconia implants Zirconia appears in two varieties, one- and two-piece implants. One-piece implants offer the absence of a microgap between implant and abutment which seems to be of bene-fi t. The surgical placement of the im-plant, though may not always meet the prosthodontic requirements and angled abutments in order to cor-rect misalignment, is not common. Secondary corrections of the shape by grinding must be avoided, as this severely affects the fracture strength of zirconia.20 Protection by use of splints is also required, though not always possible. So, two-piece im-plants were designed. Designing a zirconia implant should be based on material properties and should sim-plify surgical and prosthetic steps for the doctor. Size limitations should be considered, in order to produce an implant that is not prone to frac-tures. A clinical study by Gahlert et al. (2012) showed a marked tendency of one-piece implants with a narrow di-ameter (3.25 mm) to fracture, with a percentage that reached 92 per cent of the fractured implants.21 Threads and shape of implants should be designed according to the needs, al-ways with respect to material.

Size and shape precautions should also be applied to the implant head in order to avoid the risk of creating microcracks during implantation. The implant head if positioned at the gingival level or even higher, could eliminate the need for a sec-ond surgery, as well as to bypass the bacterial growth in the gap between implant and abutment. The decision of choosing between a one- and a two-piece implant could be infl u-enced by the design of the implant, the available space to be installed, and the prosthetic rehabilitation that follows.

Implant-abutment connectionConnection of the abutment with the implant is performed by three ways: either by screwing, cementing, or even as a combination of both. When screwing, the material of the abutment and the connecting screw is of crucial importance for the im-plant to be intact. As a consequence from titanium knowledge, screwing an abutment made from the same material as the implant was a “natu-ral” step. Screwing though zirconia inside a zirconia, unlike titanium, cannot result in a tight connection, because of the stiffness of the mate-rial. This loosening could possibly result in fracture and if this happens to the implant, it could jeopardise everything. In case of abutment failure, one should estimate the con-venience of removing the abutment screw.

A recent in vitro study by Preis et al. (2016) comes to strengthen the aforementioned performance of different implant-abutment con-nections, was investigated in six

groups of different two-piece zir-conia implant systems.22 In group 1, the abutments were cemented to an alumina-toughened zirconia implant. In group 2, the abutments were screwed with a carbon fi bre reinforced polymer screw on an alu-mina-toughened zirconia implant. In the remaining four groups, the abutments were screwed with tita-nium screws on tetragonal zirconia polycrystalline implants. A standard screw-retained titanium implant served as the control. The bonded zir-conia system and the titanium refer-ence survived without any failures. Screw-retained zirconia systems showed fractures of abutments and/or implants, partly combined with screw fracture/loosening. Failures concerning the abutment/implant region around the screw, indicate that the connecting design is crucial for clinical success.

Additionally, a study by Neumann et al. (2014) compared the fracture resistance of abutment retention screws made of titanium, poly-etheretherketone (PEEK) and 30

per cent carbon fi bre-reinforced PEEK, using an external hexago-nal implant/UCLA-type abutment interface assembly.23 UCLA-type abutments were fi xed to implants using titanium screws (group 1), polyetheretherketone screws (group 2), and 30 per cent carbon fi bre-reinforced PEEK screws. They found that the titanium screws had higher fracture resistance, compared with PEEK and 30 per cent carbon fi bre-reinforced PEEK screws.

Screwing abutments can be the trend, but cementation on the other hand could be a simpler and less time-consuming procedure as it is also shown in the study by Brüll et al. (2014).24 It is closer to the den-tist’s basic education, resembles the procedure of cementing a post in natural endodontically treated teeth and requires no extra instruments. A combination of both screwing and cementing though, could make the procedure more complicated. More studies are required to determine the proper abutment material, ce-mentation method and procedure.

The restoration materials that will be used together with their limitations should be studied.

Mostly fi xed prosthetics on single crowns or small bridges have been presented. The fracture resistance of two-piece zirconia and titanium im-plant prototypes under forces rep-resentative of a period of fi ve years of clinical loading was tested, during an in vitro experiment by Kohal et al. (2009).25 In this experiment the crown materials had no infl uence on the fracture strength of the zirconia implants. Still, in certain cases such as treating a patient with parafunc-tional chewing, a softer prosthetic material could be a wise choice. The need for further investigation on re-movable prosthetics on zirconia im-plants should be kept in mind, too.

Peri-implantitisPeri-implantitis in titanium im-plants is a serious and underesti-mated problem involving millions

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Dental Tribune Middle East & Africa Edition | 2/2018 IMPLANT TRIBUNE4

of implants. The prevalence of peri-implantitis according to the review of Zitzmann and Berglund (2008) varies between 12 and 43 per cent of implant sites.26 Many aetiological factors have been implicated, bacte-rial contamination among them. In peri-implantitis, the lesion extended apical to the pocket epithelium con-tains large proportions of plasma cells and lymphocytes but also PMN cells and macrophages in high num-bers.27,28 Peri-implantitis though has hardly been reported on zirconia implants. Zirconia demonstrates a low affi nity to bacterial plaque, small amounts of infl ammatory infi ltrate and good soft tissue integration. These properties might lower the risk for peri-implant diseases.1–3 This hypothesis is strengthened by the re-sults of the study conducted by Nas-cimento et al. (2014), where cast and polished titanium were presented with the highest incidence and to-tal count of bacteria, while zirconia showed the lowest.29

Rosenberg et al. (1991) claimed dis-tinct differences between bacterial profi les of infected and overloaded titanium implants.30 The latter were characterised by the absence of mo-tile rods, spirochetes and classical periodontopathogens, along with a predominance of Gram-positive organisms, similar to what is ob-served in periodontal health. These observations were supported by Quirynen and Listgarten in 1990.31 Failures of zirconia implants due to bacteria, should be differentiated against those of technical reasons

and the microbiota should be inves-tigated. It should be kept in mind that bacterial cells have a net nega-tive charge on the cell wall, although the magnitude of this charge varies from strain to strain. Especially on the Gram-negative bacteria, LPS as a major component of their cell mem-brane increases even more the nega-tive charge.32

Titanium is also negatively charged, thus acting repulsively to bacteria. This could be one of the reasons of success of titanium implantation in

a contaminated environment. Zir-conia though has no electric charge. Depending on the roughness and the hydrophilic surface of every zirconia implant system, contami-nation may be easier to occur and this could be a reason of early fail-ure when zirconia is implanted in a contaminated environment. Studies are needed to clarify whether the lat-ter could affect the osseointegration result and what is the relative danger comparing to titanium. Local disin-fection could minimise the risk in immediate implantation using the

help of ozone and autologous plas-ma. Nutrition and food supplements could also be helpful, too.

Intolerance to titanium and genetic predisposition to infl ammation has been introduced as an additional and independent risk factor (Odds Ratio 12 and Odds Ratio 6 respec-tively) for peri-implantitis.33 The au-thors propose a direct effect of the released microparticles of titanium on the immunological mechanism of the body that could possibly ini-tiate peri-implantitis. Zirconia parti-cles on the other hand have no effect on the release of TNF-a.34 Titanium microparticles are released as a re-sult either of friction, electrochemi-cal corrosion, or the synergistic effect of both and can either be taken up by macrophages, remain in the intercel-lular space near the releasing site, or systemically migrate in organs such as liver, spleen and lung, as Olmedo et al. (2003 and 2002) found.35,36

Same group of authors made a long-term evaluation of the distribution, destination, and potential risk of both TiO2 and ZrO2 microparticles, in an animal study.37 They evaluated:

(a) the presence of particles in blood cells and liver and lung tissue, (b) Ti and Zr deposit quantitation, (c) oxidant-antioxidant balance in tissues, and (d) O2– generation in alveolar mac-rophages.

Ti and Zr particles were detected in blood mononuclear cells and in organ parenchyma. At equal doses and times post administration, Ti content in organs was consistently higher than Zr content. Ti elicited a signifi cant increase in O2– genera-tion in the lung compared to Zr. The consumption of antioxidant en-zymes was greater in the Ti than in the Zr group.

ConclusionScientifi c studies are promptly needed to fulfi l gaps like long-term clinical evaluations of all existing zirconia implant systems. Protocols used to design, manufacture and test titanium implants cannot simply apply to produce and evaluate the zirconia ones. Every step, from pro-duction to surgery and prosthetic reconstruction needs to be carefully planned, with respect to the proper-ties of the new material. Accordingly, the advantages of zirconia would be fully benefi cial and the risk of failure could be minimised.

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Dr Sofi a Karapataki Implant and Periodontal ClinicAdrianeiou 4211525 Athens, GreeceTel.: +30 210 671138-0info@skarapataki.grwww.leadingimplantcenters.com

Microparticles released by titanium on the immunological mechanism of the body

could possibly initiate peri-implantitis.

March-April 2018 | No. 2, Vol. 8PUBLISHED IN DUBAI www.dental-tribune.me

orthointernational magazine of orthodontics

techniqueTongue star 2 (TS2) – System for rapid open bite closure

case reportUse of diode laser in the treatment of gingival enlargement during orthodontic treatment

industry reportSensorimotor training with RehaBite during orthodontic treatment

22017

issn 1868-3207 Vol. 2 • Issue 2/2017

SUBSCRIBE NOWwww.me.dental-tribune.com/e-paper/Introducing Dr. Naif Almosa -

Chairman of the Digital Orthodontics Symposium Dubai

By Dental Tribune MEA / CAPPmea

Dental Tribune MEA has the pleas-ure to interview Dr. Naif Almosa, Assistant Professor at the Division of Orthodontics, and Consultant in Orthodontics. Dr. Almosa received his BDS dental degree from College of Dentistry, King Saud University in 2006 and continued developing further at Odontologen, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden where he com-bined a postgraduate orthodontic residency program and PhD degree.

Dr. Almosa joined the orthodontic faculty of the Department of Pedi-atric Dentistry and Orthodontics at the College of Dentistry, King Saud University in 2014, where he cur-rently serves as a full-time faculty. At the College, Dr. Almosa is involved in teaching both undergraduate, post-graduate students and research. In 2014, Dr. Almosa assigned to be the Director of Internship Program for three years in addition to his full-time academic appointment. Cur-rently, Dr. Almosa is the Chairman of Paediatric Dentistry and Orthodon-tic department at KSU.

Dr. Naif Almosa, please if you can give us some insights into your background of life, work and education hailing from Saudi Arabia?I was born in November 1981, mar-ried and father of three angels. I received the bachelor’s degree of dental science from King Saud Uni-versity (KSU) in 2006 and completed the internship program in 2007. After this I joined the orthodontic residency program at Gothenburg

University in 2009 and gained the National Swedish Board of Ortho-dontics in 2012. I started the PhD pro-gram while I was resident in the clini-cal program in 2010 and completed my PhD degree in April 2014. In May 2014, I returned to Saudi Arabia and joined the department of Paediatric Dentistry and Orthodontics at KSU. In September 2014, I was assigned to be the Director of Internship Pro-gram until the summer of 2017. In April 2017, the Rector of the Univer-sity assigned me as the Chairman of Paediatric Dentistry and Orthodon-tic department to present day.

As an active member and am-bassador for the Saudi Ortho-dontics Society, how impor-tant is it to stay continuously up to date as an Orthodontist?Very important. In Orthodontics, there is no excuse to stop learning. Technology is very fast in coming up with new discoveries so it is up to us to keep pace and combine it into our clinical practice. I can never empha-size enough how much we need to take advantage of the information that is readily available to us.

Orthodontics is growing to be an industry-driven specialty, and I strongly believe that as profession-als the best way for us to be updated and gain more insight and critical thinking in the face of all these new products and technology, is to at-tend the national scientific meet-ings, workshops, and international conferences.

What are some of the activities organized by the Saudi Ortho-

dontics Society? What are the benefits of the members and why should non-members reg-ister? The Saudi Orthodontics Society (SOS) is now in its 12th year, and we have held a fair number of confer-ences, annual and semi-annual meetings, workshops, etc. Always with the end goal of excellence in the orthodontic field, we have invited speakers from different parts of the world to bring to us their experience and knowledge. Being a member of the SOS, you get the opportunity to be amongst your peers and stay up to date in orthodontics. In my opin-ion, to learn from and interact with these colleagues would be enough incentive for non-members to reg-ister. Surely, if you go through our website, the SOS members do have the added benefit of preferential rates on some activities as well as ac-cess to specific journals.

You are now part of the facul-ty at College of Dentistry, King Saud University. Could you share more information on the Orthodontics programme being run by the college?In the KSU Ortho program, we are actively engaged in the education of undergraduate students consistent with the development of compe-tency in general dentistry. The de-partment offers didactic, pre-clinical and clinical experiences in paediatric dentistry and orthodontics integral to comprehensive patient care. We also offer post-graduate programs for specialty training in Paediatric Dentistry, and Orthodontics. This is a 36-month program leading to a Master’s degree. In addition, three years ago, we started the Doctorate program in both specialities, Pedo and Ortho. The doctorate program is a four years full time program, which includes didactic, clinical, and research activity where the students must write a thesis at the end of the program under supervision of our unique faculty members.

Dr. Naif Almosa, following your active and extensive education, how do you reflect on your ed-ucation experiences in Saudi Arabia as well as in Sweden?Under the curriculum provided by the KSU in my undergraduate years, I was able to gain a solid background

in dentistry. I cannot speak about the kind of curriculum provided by other schools here or abroad, but it’s a given that our culture some-what limits some learning aspects in terms of the possible exposure we could otherwise gain from or take advantage of. I must admit the educational experience was quite a different scenario to what I encoun-tered in Sweden, but my background in KSU proved to be more than ad-equate to help me adjust and fit it.

Do you remember the experi-ence of bridging the gap be-tween your education and your first working experience?The very first patient I treated as a fully independent and registered professional dentist was one of my friends and it was a great and unfor-gettable moment. The reason it im-pacted me was not due to the clinical practical treatment, as this was con-tinuously drilled into us as students; but moreover, the experience from a moral and ethical aspect. I was now in the position not only to treat the patient, but to guide him through several possible outcomes. This is where education lets go of us, and where our personal choices come in to set the tone of our professional world.

What advice would you pro-vide your students who look up to you as a mentor and role model for their future life?During my time as the Director of the Internship Program, I made it a point to provide the interns with as much exposure as possible to all the career options they could take. Internship is the transitional stage where they change from a guided student to an independent professional and it is critical that they have an idea of all the possible areas they can enter in the dental profession. It is not a one-stop trip; you will go through dif-ferent experiences. Awareness and learning is very important to me. I would advise the students to never stop learning. Each person you meet will teach you something, whether professionally or as a human being. Professional excellence is a worth-while goal, but do not forget to live your life.

How do you rate the level of dentistry in the field of Ortho-dontics in the Middle East re-gion, particularly in the GCC?

Orthodontics in the Middle East is evolving at a rapid pace. I believe that it is improving with the increas-ing addition of new orthodontists who have been graduated from dif-ferent schools around the world. We are also seeing more companies be-ing established here that are enhanc-ing innovations in digital orthodon-tics, and of course, we are now able to have global collaborations through e-learning and scientific meetings in different parts of GCC. I must admit that we are still lacking a more com-prehensive educational program for our patients in GCC, especially with regards to the importance of oral hy-giene and how it impacts orthodon-tic treatment. Unfortunately, most of the parents in our region have no idea when is the proper time for their kids to visit the orthodontist, because in some cases, this usually results to a very serious and more complicated treatment procedure when their children are already grown-up.

Digital Dentistry is slowly tak-ing over the dental profession, even in Orthodontics. How do you see the future of dentistry, orthodontics and the imple-mentation of digital into your working profession?Digital dentistry has revolutionized dentistry. There are unlimited pos-sibilities. Prosthodontics has notably seen a lot of progress with its rapid integration of the digital process like the CAD/CAM, and in radiology, there’s the cone beam computer tomography. Orthodontics, with its multidisciplinary needs, has been a bit slower, but digital photography, CAD/CAM, laser and intra-oral scan-ners have brought about so much progress. Again, even with all the ease that technology is bringing to our practice, adequate training is still very much a requirement. Never stop Learning. Digital Dentistry will save time, enhance patient comfort, allow more accurate impressions and show patients creative virtual treatment plan options moving away from the old notion that the dental clinic is “a place to be feared”, changing into “a place to be experi-enced”

We appreciate your valuable insights and wish you the very best in your fu-ture endeavours.

Interview with Dr. Naif Almosa, Chairman, Department of Paediatric Dentistry and Orthodontics, Assistant Professor and Consultant in Orthodontics at King Saud University, Riyadh - Saudi Arabia.

Dr. Naif Almosa, Chairman, Department of Paediatric Dentistry and Orthodontics, Assistant Professor and Consultant in Orthodontics at King Saud University, Riyadh, KSA

Dental Tribune Middle East & Africa Edition | 2/2018 ORTHO TRIBUNEE2

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The orthodontic patient - From hell to heaven

By E.M.S

If you’re anything like me, my heart would sink a little when I would see that a teenage patient in active or-thodontics was booked to see me. Who would walk through the door? Would it be a mouth full of food de-bris stuck in what looked like moldy orthodontic brackets and profusely bleeding gums? Would I see impos-sible to reach staining around the brackets or think my patient just ate a packet of Cheezels™ only to fi nd out that he or she had just not brushed his teeth since the last time I saw them?

I used to loath this type of patient, not just because I could fi nd enough food in their brackets to feed a small nation but because I was never satis-fi ed with the results I’d achieved af-ter I’d fi nished their clean.

Far too often, I felt under pressure to get their teeth cleaned in the “child” timed appointment slot, never feel-ing like I had removed everything. I was always feeling frustrated try-ing to manoeuvre my ultrasonic tip around brackets, trying to use a pro-phy handpiece and gluggy prophy paste to remove tenacious sticky mature plaque from modules and on the gingival side of the bracket. As I frantically worked away, I would be loathing the patient in the chair; blood, sweat and tears from both of us was going into the appointment with a lacklustre result!

Good oral hygiene vital for orthodontic patients Good oral hygiene is paramount to successful orthodontic treat-ments. Without good oral hygiene, a patient’s outcome will be com-promised. This was frustrating me.

In a journal article by Lovrov S, et al (2007),1 it was shown that “despite improvements in materials and preventative efforts, orthodontic treatments continue to carry con-siderable risk of enamel deminer-alisation. Each patients’ prophylactic efforts, including fl uoride use are of paramount importance in prevent-ing white spot lesions”. In another article, by Ren, et al (2014),2 it showed that “high treatment demand and the occurrence of biofi lm-related complication requiring professional care, make orthodontic treatments a potential public health threat”. Knowing how important it is that the professional clean be good and all biofi lm be removed just added to my stress. I knew that I could never remove all the biofi lm and that there would be areas around the brackets my ultrasonic or prophy cup just couldn’t get to. Then, if you add in the mix that the patient already has

some demineralisation of the enam-el where the ultrasonic couldn’t be used, then the frustration and diffi -culty of the appointment just dou-bled again.

In search of a better solutionCombining all of the above prob-lems made me want a better solu-tion. I want to provide my patients with the best treatment possible and I don’t want my patients leaving their appointments with biofi lm still trapped in modules. After initially discovering success with AIRFLOW® (EMS) for implant patients, I was interested in what it could offer my orthodontic patients.

What I discovered is that by using AIRFLOW in combination with Guid-ing Biofi lm Therapy, I was getting amazing results. If you had asked me before AIRFLOW to plaque dis-close my ortho patients, I may have thought you were either crazy or you hated me. Before AIRFLOW, I didn’t want to plaque disclose my patients who have orthodontic appliances as it would have provided proof of the areas where I left biofi lm behind be-cause I couldn’t get to it. I now plaque disclose every single one of my pa-tients as part of the “8 steps” of the Guided Biofi lm Therapy protocol.

Guided Biofi lm TherapyBy using the Guided Biofi lm Therapy protocol, you achieve predictable biofi lm removal with 100% and 360 degree accessibility. It’s safe and ef-fective around the sulcus, there is no change in the surface of the ap-pliance and not only is it more com-fortable for the patient with better results, I am happy!

I feel so much happier with my re-sults not only at the time of the ap-pointment but because the long term benefi ts for the patient in terms of motivation and education are so much better. Not only do the patient and I see better results, but it is also clinically proven that using a plaque disclosing solution to guide biofi lm removal shows better outcomes for the patient. In Botti et al 2010,3 Bas-tendorf et al 2016,4 and Viorica et al 2013,5 all confi rm higher effi ciency in professional prophylaxis when done with the use of a disclosing agent. In the study by Viorica et al, Dental Plaque - Classifi cation, Formation and Identifi cation,5 it was shown that “dental plaque diagnosis us-ing coloured solutions is one of the easiest and fastest ways to diagnose

Tabitha Acret explains how Guided Biofi lm Therapy has revolutionised how she treats orthodontic patients

Fig. 1: AIRFLOW in action on orthodontic brackets

Fig. 2: The 8 steps of the Guided Biofi lm Therapy compass

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Dental Tribune Middle East & Africa Edition | 2/2018ORTHO TRIBUNE E3

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dental plaque, which favours its sub-sequent removal under permanent control during the intervention. Using AIR-FLOW, removal of dental plaque approaches a ratio of 100%”.

More than cleaning bracketsThe are two other key reasons why following the Guided Biofilm Thera-py protocol is impressive for ortho-dontic patients as well as routinely in all prophylaxis procedures. The first is the long term health of the enamel and gingiva. By using AIR-FLOW technology combined with AIRFLOW PLUS powder, I know that I am providing the least damage to the patients enamel and orthodontic appliances. In A clinical comparison of the efficacy and efficiency of two professional prophylaxis procedures in orthodontic patients,6 Ramaglia et al show that “In orthodontic pa-tients, use of AIRFLOW polishing is a lot safer, efficient and effective to remove stains and dental plaque in comparison to rubber cups and pumice”.

The second great thing was that I now had time to finish within the appointment time. I wasn’t feeling so under the “pump”. I used to find that I was always running late in these appointments and now I was finishing easily within the time al-located. In Effects of an air-powder polishing system on orthodontically bracketed and banded teeth,7 Barnes et al show hat “Air polishing around orthodontic brackets and bands was not only effective but time efficient. There were no detrimental effects to any composite material or cement in comparison to rubber cup and pum-ice”.

ConclusionBy using Guided Biofilm Therapy with AIRFLOW technology combined with appropriate home OHI instruc-

tions and motivation, I am provid-ing the best treatments possible for my patients. I love Guided Biofilm Therapy; it’s changed my attitude toward treatment, my treatment results and my patients’ long term outcomes. Guided Biofilm Therapy is evidence-based dentistry; it is the new standard of care we should all be looking to reach.

For information on EMS and Guided Biofilm Therapy, visit www.ems-dental.com and follow EMS Australia and New Zealand on Facebook - fa-cebook.com/emsausnz. To test drive this revolutionary protocol in your practice today, book a free in-practice Guided Biofilm Therapy demonstra-tion by emailing info@ems-ausnz.com or call 0405-095-867.

References1. Lovrov S, Hertrich K, Hirschfelder U. Enamel Demineralization during Fixed Orthodontic Treatment - In-cidence and Correlation to Various Oral-hygiene Parameters. J Orofac Orthop. 2007 Sep;68(5):353-63.2. Ren Y, Jongsma MA, Mei L, van der Mei HC, Busscher HJ. Orthodontic treatment with fixed appliances and biofilm formation - a potential pub-lic health threat? Clin Oral Investig. 2014 Sep;18(7):1711-8.3. Botti RH, Bossù M, Zallocco N, Ves-tri A, Polimeni A. Effectiveness of plaque indicators and air polishing for the sealing of pits and fissures. Eur J Paediatr Dent. 2010 Mar;11(1):15-8.4. Schwarz F, Becker K, Bastendorf KD, Cardaropoli D, Chatfield C, Dunn I, Fletcher P, Einwag J, Louropoulou A, Mombelli A, Ower P, Pavlovic P, Sahrmann P, Salvi GE, Schmage P, Takeuchi Y, Van Der Weijden F, Ren-vert S. Recommendations on the clinical application of air polishing for the management of peri-implant mucositis and peri-implantitis.

Quintessence Int. 2016 Apr;47(4):293-6. doi: 10.3290/j.qi.a35132.5. Chetrus V, Ion I.R. Dental Plaque - Classification, Formation and Identi-fication. Int J Med Dent. Apr-Jun 2013, Vol. 17 Issue 2, p139-143. 5p.6. Ramaglia L, Sbordone L, Ciaglia RN, Barone A, Martina R. A clinical com-parison of the efficacy and efficiency of two professional prophylaxis pro-cedures in orthodontic patients. Eur J Orthod. 1999 Aug;21(4):423-8.7. Barnes CM1, Russell CM, Gerbo LR, Wells BR, Barnes DW. Effects of an air-powder polishing system on or-thodontically bracketed and banded teeth. Am J Orthod Dentofacial Or-thop. 1990 Jan;97(1):74-81.

Fig. 3a-c: Top to bottom: Initial situation; after disclosing; and after Guided Biofilm Therapy.

Tabitha AcretTabitha Acret is a quali-fied dental hygienist and has been part of the den-tal industry for 20 years. She has worked as a den-tal nurse, dental recep-

tionist and practice manager. She holds a BOH from Newcastle University and is currently undertaking further studies in Sleep Medicine. Tabitha is registered with the Australian Dental Board and was the previous chair for the NSW Dental Hy-gienist Association Australia Ltd and is the current NT Director for the DHAA Ltd. She is a regular at CPD events with a pas-sion for learning and making a difference in her patients’ lives. Tabitha currently works 3 days a week in private practice, was a previously a clinical educator one day a week at Sydney University for 2nd year BOH students until her recent move to the Norther Territory to help set up an implant maintenance program in private practice. Tabitha is also an educator with the Swiss Dental Academy..

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Dental Tribune Middle East & Africa Edition | 2/2018 ORTHO TRIBUNEE4

Efficient Bonding Protocol for the Insignia® Custom Bracket SystemBy Dr. Angle Lee, Dr. Chris Chang & Dr. W. Eugene Roberts, Taiwan

Insignia® (Ormco, Glendora, CA), is a computer-assisted design and manufacturing (CAD/CAM) process for producing a specific fixed appli-ance system to treat a malocclusion. Custom brackets and archwires to achieve the prescribed alignment are produced by a reverse engineer-ing process, based on the digital set-up of final intermaxillary occlusion. Precise placement of each bracket is critical for producing a threedimen-sional (3D) alignment to efficiently accommodate the final rectangular finishing wire, with no need for de-tailing adjustments. Positioning jigs for each bracket are fabricated to as-sist the clinician in accurately bond-ing or rebonding the prescribed cus-tom attachment on each tooth.1-3 The purpose of this report is to describe a standardized protocol for efficiently placing the custom appliance in the prescribed position. All orthodontic supplies and auxiliaries described in this article were produced by the same manufacturer (Ormco, Glen-dora, CA), unless otherwise stated.

Preparation for BondingPrior to the installation appoint-ment, the clinician and assistant(s) should inspect the following items in the patient’s kit box (Fig. 1):

1. Custom prescription brackets with well fitted application jigs (Fig. 1c): The brackets for each quadrant are packed together.

2. Six upper and six lower custom archwires with labels (Fig. 1d).

3. A setup of individual replacement jigs for each tooth (Figs. 1e-f): The first and second molars have brackets al-ready loaded.

4. Case paperwork (Fig. 1g): Clinicians are alerted to anticipated bracket interference with occlusion, that re-quires bite turbos or other compos-ite buildup on the occlusal surface to open the bite. If there is substantial crowding some brackets may be des-ignated for placement later in treat-ment.

Clinical tip: The custom-fit group jigs should be dry fitted to dental casts of the malocclusion for two rea-sons: (1) check the bonding positions, (2) determine if there is any jig inter-ference when adjacent brackets are properly positioned (Fig. 2)

Bonding Process1. Tray Arrangement:Place the jigs and bonding instru-ments in the desired order, usually in the progression that they are used (Fig. 3). The arrangement may vary according to the desired tray posi-tion relative to the patient, and the handedness of the clinician and as-sistant.

2. Isolation Procedure:Begin moisture control by placing dry aids on the cheek mucosa to block the parotid gland orifice and isolate the soft tissue. Super absor-bent pads are used between lower molars and the tongue to control saliva secretion by the sublingual glands. An OptiView® lip and cheek retractor is positioned to provide a clear view of the entire oral cavity

including the buccal surfaces of the molars (Fig. 4).

3. Step-by-Step Protocol:(1) Dry fit the group jigs to the initial casts to identify any problems in se-quentially positioning the bondable pads on each tooth.(2) Apply etching-gel for 30 seconds to the facial surface of each tooth.(3) Rinse throughly with water spray for a minimum of 5 seconds per

tooth and air dry.(4) Apply the bonding agent (Ortho Solo®) onto all teeth to be bonded. No air-drying or light curing step is required.(5) Apply a thin coat of adhesive to

each bracket pad with an application instrument such as LiquidSteel Poly-Fill Plasma+® (Carl Martin, Solingen, Germany).(6) Use cotton tweezers to grip the jigs.

(7) Roll the jigs, from the lingual cusp or incisal edge, to the facial surface to prevent disturbing the adhesive layer by sliding the pad along the

Fig. 1: The patient’s kit box shown (a and b) contains custom prescription brackets fitted to placement jigs (c), six upper and six lower custom archwires with labels (d), replace-ment jigs for each tooth if rebonding is required (e and f), and case paperwork describing special treatment procedures (g).

Fig. 4: Compared to conventional retrac-tion (left), an Optiview® lip and cheek re-tractor (right) is more comfortable for the patient, and improves intra-oral visibility.

Fig. 5: Insignia® bonding procedures are organized into a step-by-step protocol: (1) dry fit the group jigs, (2) apply etching-gel, (3) rinse, spray, and dry, (4) coat etched surfaces with the bonding agent (primer), (5) apply a thin layer of adhesive resin to each bonding pad with a filling instrument, (6) use cotton tweezers to grip the jigs, (7) rotate the pad and jig from the lingual cusp or incisal edge to the facial surface, and apply pressure from a 45-degree angle (yellow arrow), (8) use a microbrush dipped with bonding agent to clean off excess adhesive, (9) spray the jig-bracket assembly with water, (10) use a Weingart plier to release the jig from the brackets on the mesial and the distal surfaces, and then by rolling it gently to the lingual (yellow curved arrows) to remove the jig(s) from the upper (11) and lower (12) arches.

Fig. 2: Group jigs are placed on dental casts to check the fit. Jig interference (yellow ar-rows) is noted between the lower left canine and 1st premolar, during the prescribed bonding procedure. Both occlusal (a and b) and the left lateral perspectives (c) are shown. It follows that the lower left 1st premolar and 1st molar group jig must be removed be-fore applying the group jig to bond the lower left canine and adjacent incisors.

Fig. 3: Ensure bonding instruments are laid out in the desired order: (a) mirror and cotton tweezers, (b) custom prescription brackets with custom fit placement jigs, (c) dry aids and super absorbent pads, (d) scaler, Weingart plier and filling instrument, (e) lip and cheek retractor, (f) bonding agent, etching-gel, microbrushes, (g) adhesives and uni-dose ap-plicator. See text for details.

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